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SANITARY PERMIT APPLICATION <br /> t��Lllr�tlra In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE ANITARY ERMIT#U�Uo3 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C1-� ����^ll61 ) <br /> 8%x 11 inches in size. ❑ Check if revision to previous application <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> LEK '/a ''/a, S 2—'3 T'{0 , N, R Jb E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# OtMKl# <br /> ER ES AN/ . S . Sul 2130 1 -.�, 2 IL. 3 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> M?LS N . � 31It C5r1 dOf_. fo ?- 1-33 <br /> It. TYPE OF BUILDING: (Check One) ❑ State Owned OVILLAGE NEAREST ROAD <br /> E@ TOWN CY�KI�Nn $R y NIt,Solhl <br /> ❑ Public M 1 or 2 Fam. Dwelling--#of bedrooms 7 PARCELTAX NUMBERS) <br /> ) <br /> III. BUILDING USE: (If building type is public,check all that apply) —O3—C.(^^ <br /> 1 ElApt/Condo W <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line 8 if applicable) <br /> A) 1. �n New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 ElMound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 n Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> ��jj�� REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Q,I pEELEV/ATION <br /> o�0 8 0 I l�Z I T• Feet I (• ] Feet <br /> VII. TANK CAPACITY Site <br /> ingallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New istin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdino Tank <br /> Lift Pump Tank/Siphon Chamber <br /> Vill. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> PQl A 3` 216 '1�s $b6- yrs <br /> Plumber's Address Street,City,State,Zip Code): <br /> 3S W6t35?gt2 LJI • 548`13 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ae Issued Issuing Agent Signatu (No Sta ps) <br /> Approved ❑ Owner Given Initial �y� rcharge Fee) _`^ <br /> Adverse Determination J o <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />